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Chapter 1
Wound Healing and Care
Abnormal Healing—Hypertrophic Scars and Keloids
Bill Rhodes and Louis Carter
The science of basic wound healing is covered well in basic surgical textbooks.
It is imperative that surgeons everywhere have a solid understanding of the
principles of wound healing. The surgeon is constantly confronted with the
difficult task of wounds in a variety of stages within the healing process. This
chapter will help one better understand the abnormal wound healing processes
that lead to hypertrophic scarring and keloid formation and give one basic
steps in preventing and treating these conditions in remote areas. Other
chapters will deal with chronic wounds and ulcers and Vacuum Assisted
Wound Closure and skin grafts.
There are many causes of abnormal healing.
Some of the more common
causes in Africa are:
1. Anemia--though the hemoglobin must be below 5 grams before it will
directly affect wound healing, it frequently coexists with chronic malaria, worm
infestation, general malnutrition, immunocompromised conditions and
poverty.
2. Diabetes is common and uncontrolled diabetes leads to impaired
fibroblasts and collagen deposition and epithelialization.
3. Untreated AIDS is a major cause of delayed wound healing. The first
sign of immunocompromised state maybe a chronic wound
4. Atherosclerosis is seen more than expected.
5. Venous stasis affects wound healing and lack of elevation is a common
cause of slowly healing wounds.
6. Aging
7. Malnutrition with deficiency of
A. amino acids and a low serum albumin
B. vitamin C and A deficiency
C. trace elements
8. Infection
9. Sickle Cell Anemia
10. Drugs, tobacco, beetle nut use
11. Environment—excessively wet or dry climates may contribute to poor
wound healing
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With any slowly or non-healing wound, a reasonable workup to exclude the
above factors and conditions should be carried out. The most likely causes
are diabetes or other immunocompromised state, stasis, sickle cell,
malnutrition, and aging.
The chapter on chronic wounds discusses
management of the subacute or chronic wound.
Excessive scar formation
There are two types of excessive cutaneous scar formation.
They are
hypertrophic scarring and keloid formation.
Though both result in an
overgrowth of scar with excessive collagen formation, it is important to
differentiate between the two.
Hypertrophic scars
Hypertrophic scars are self-limited, raised, excessive scar tissue that remains
within the border of the wound. They can occur within weeks after the original
wound injury. Hypertrophic scars occur in persons of any age and at any
wound site, either surgically created or by traumatic injury.
They tend to
spontaneously regress in size over time and are generally more responsive to
treatment compared to keloids.
Tension at the site of the wound is often
responsible for the formation of hypertrophic scars. Though hypertrophic scars
may be found anywhere, there is a higher propensity for them to occur on the
chest, the upper back, or the deltoid regions. Other factors contributing to
hypertrophic scar formation are a prolonged inflammatory response, infection,
foreign body (e.g. suture material) and wound orientation different from the
direction of skin tension lines. Patients tend to complain of their appearance
and pruritic sensation.
Small hypertrophic scars generally respond well to a
steroid injected into the lesion like triamcinolone acetonide (Kenalog). A dose
of 10-40mg (usually comes in 40mg/1ml) is injected into the scar using a 2527 gauge needle. Unlike keloids, hypertrophic scars normally may be excised
and closed primarily in a tension free manner in the direction of relaxed skin
tension lines without fear of recurrence. This is most effectively performed by
excising a linear scar in a fusiform fashion with a 4:1 length to width ratio of
the wound to assist in closure. Scars not oriented along relaxed skin tension
lines, can be reoriented in a more tension free direction using a one or more
simple z-plasties.
Compression therapy with Spandex or other elastic
material can be used in garments to apply pressure. (See chapter 33.) These
garments maybe used for treatment and also for prevention of hypertrophic
scar in acute wounds with a tendency for hypertrophic scars.
Silastic gel
sheeting may also be used if available. When special garments are not
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available, bandages such as an Ace or Crepe may be used to apply pressure.
When primary closure is not possible, a split thickness or full thickness graft
can be used. Once the wound has healed pressure may be applied to prevent
recurrence.
Often burns are associated with hypertrophic scarring and with contractures if
over joints.
These can also be excised with skin grafting or a local flap
transfer. It is best to wait 12 months for the scar to mature especially if some
of the scarred skin will be used in a local flap. There may be a place for serial
excision in large hypertrophic scars.
One must be sure that it is a
hypertrophic and not a keloid before proceeding with this treatment option.
Rarely after complete surgical excision there may be recurrence.
Waiting for
these recurrent scars to mature before any further surgery is advised. If one is
close to a large city, low dose irradiation may be helpful in the control of
recurrent hypertrophic scars. Cocoa butter is often available and has been
found by some to help control itching. (See Chapter 15 Burn Reconstruction)
Keloids
Clinically, keloids are identified by continued excessive growth of the scar
beyond the border of the actual wound. Keloids are less common than
hypertrophic scars and appear to have a genetic component that primarily
affects African and Asian populations. This abnormal proliferation of scar
tissue with immature collagen synthesis up to 20X normal, as compared to
14X in a hypertrophic scar, can form either from a surgical incision, burns or
from a simple and sometimes forgotten traumatic injury to the cutaneous
tissue. Compared to hypertrophic scars, keloids do not naturally regress in
size, but may continue to enlarge over time. They are also predominantly in
high-tension areas of the skin such as the shoulder, anterior chest and neck.
Keloid formation generally begins within a year after injury. Other significant
risk factors, similar to hypertrophic scarring, are wounds that heal by
secondary intention and wounds with chronic inflammation as in earring sites.
Patients complain of the keloid’s unsightly appearance as well as pruritic and
burning sensation at or around the keloid.
The treatment of keloids can be frustrating. The most important consideration
is prevention in those that are at a high risk for keloids. Great care should be
taken in closing wounds in a tension free manner, paying attention to the
direction of the scar and with an appropriate soft tissue layer closure.
Monofilament suture may be helpful in causing less reaction and sterile
technique should be followed in minimizing the risk of subsequent infection.
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No readily available modality is effective to completely prevent keloid formation.
Hypertrophic and keloid prone areas should be carefully closed, especially with
long lasting deep dermal sutures.
In large cities low dose irradiation is usually available and can be administered
within a few days of keloid excision. There are different treatment regimens
but irradiation is often given daily over 3-4 days. The results are outstanding
on the smaller keloids as those around the ear. Irradiation should not be used
in children. The injection of steroid into the keloid is generally the best first line
treatment for small keloids. The corticosteroid of choice is triamcinolone
acetonide (Kenalog). The goal is to inject the body of the keloid scar with 1040 mg/ml using a 25-27 gauge needle at 6-8 week intervals. The triamcinolone
is mixed half and half with a local anesthetic. This not only provides
anesthesia for the injection but gives increased volume for the injection. The
author will penetrate just beneath the skin with the needle and then make
multiple radial sticks throughout the keloid prior to injection of the steroid.
The needle is then withdrawn to just beneath the skin and the steroid injected.
This allows the solution to fill the keloid in every direction. Oftentimes, a larger
gauge needle is needed with larger keloids. Some feel the internal pressure
from within the keloid by the injected fluid is significant in the resolution of the
keloid.
It may be impossible to inject very hard keloids and these require
surgical removal.
Care should be taken not to inject the steroid into the
subcutaneous tissue that may result in atrophy and loss of pigmentation in the
surrounding tissues. The results of steroid injections in small keloids can vary
from partial flattening to nearly complete or complete resolution. Large keloids
cannot be effectively treated with triamcinolone.
As with hypertrophic scars, compression therapy has been effective as an
adjunct to treating keloids after steroid injection and after keloid excision.
Patients should be encouraged to massage keloids regularly after steroid
injections. Keloids resulting from earrings can often be helped by creating
special large earrings that apply pressure after steroid injection. These are
commercially made but it may be possible to create a device to apply pressure.
Garments made of spandex, fabricated to provide consistent pressure may be
of help in the treatment of keloids occurring on the trunk, extremity or even
face and neck. If one has Spandex or a similar elastic material, a seamstress
may be able to custom-make a garment to apply constant pressure. Often
these can be worn for at least 12 hours at night and sometimes all day.
Silastic gel can also be applied to the area if it is available. (See Chapter 32)
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If it is decided to proceed with excision of a keloid, the patient should be
informed preoperatively of the high rate of recurrence. Excision with primary
closure has recurrence rates in keloids of 50% and often with recurrence of
equal or larger size. Steroid injection should be administered at the time of
excision into the superficial dermal edges of the wound. This can be repeated
at two to three week intervals postoperatively. Incisions should be made in
relaxed skin tension lines whenever possible. If a tension free closure is not
possible, a split thickness or full thickness skin graft may be best.
Additionally, methotrexate can be given as a single oral dose, 15-20 mg. in an
adult, one week before keloid excision and then continuing for three - four
months after surgery. This may be helpful in limiting keloid recurrence. In
younger patients a dosage of 0.3 mg /kg orally is used weekly for at least 6
weeks after surgery.
Compression therapy if possible should also be used
after keloid excision.
Many other medical therapies, which may not be available to you, have been
used with inconsistent results.
Patients with keloids will travel many
kilometers and pay large sums of money for any help they can get.
Unfortunately, complete cure is rare and especially in remote areas with limited
treatment modalities.
Sycosis Barbae and Folliculitis Keloidalis
Infections in hair follicles can lead to keloid formation. These conditions seen
in men, usually of African descent, are sycosis barbae and folliculitis keloidalis.
Sycosis barbae involves the bearded areas of the face and begins as a
folliculitis after shaving. Sycosis is a papulopustular inflammation of the hair
follicles. This is also called barber’s itch and folliculitis barbae. It may begin
as a superficial staphylococcal infection. Repeated episodes of infection lead
deep-seated infections, multiple discharging sinuses and keloid formation.
These deep, entrenched infections are difficult to treat and they do not respond
well to antibiotics alone. Since these keloids are chronically infected and
constantly draining, they should be excised once any acute infection is under
control.
Folliculitis keloidalis involved the nape of the neck, occipital scalp, and initially
may look like a dermatitis or acne. This may be secondary to a haircut but
often there are ingrown hairs that irritate the wall of hair follicles and lead to
inflammation.
Over time keloids may develop in these chronically infected
areas.
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Fig 1
Folliculitis Barbae
Both of these conditions may initially respond both oral antibiotics as
Doxycycline and topical antibiotics where available.
Once the infection is
under control, surgery may be performed. With deep, follicular infections,
antibiotics will not control the infection that is deep within the sinuses.
Complete excision with delayed skin grafting is recommended. Excision must
be carried down below the level of the hair follicles in the subcutaneous tissue.
In most of these cases, it is important to leave the wound open and take the
patient back for one or more “second look” procedures to further débride
questionable areas.
Surgical technique: surgery is performed under general anesthesia with
Xylocaine/Lidocaine with adrenalin infiltration in the skin to decrease the
bleeding and also help with visualization. This is often diluted when dealing
with large keloids as shown in the case below.
Electrocautery is useful in
minimizing bleeding, but one must be careful not to damage vital structures
within the area of surgery. Repeat débridements are carried out every other
day. In subsequent débridements the Weck or Humby knife blade is used for
tangential excision. Since important structures maybe nearby in sycosis
barbae, especially the marginal mandibular branch of the facial nerve, the
author feels that tangential excision down to viable, non-infected tissue is the
safest method of débridement. As soon as the bed is clean without evidence of
residual infection, it is skin grafted. Complete and adequate débridement may
require 7-10 days. Thick split thickness sheet grafting is ideal, but a meshed
graft without spreading it out, may be the safest, if one is concerned about
residual deep infection. See case below. Where low dose radiation is available,
a single dose after skin graft healing may reduce recurrence.
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Since infection is usually the cause for the keloid, recurrent keloid formation
may be prevented by careful shaving and early antibiotic treatment of any
recurrent infection. The patient may need to change from mechanical shaving
to using chemical depilatory agents – creams or powders that will be available
in city pharmacies and stores.
In the author’ experience, recurrence is not likely if one follows these
guidelines. Additional measures to prevent recurrence are: A compression
garment maybe placed over the graft, as custom made ones seen in chapter 33
or this could be a dressing with a neck collar or an elastic bandage wrap.
Triamcinolone may be injected around the edges of the graft every month for
several months if it is available. Triamcinolone 40 mg. is diluted with lidocaine
1:1 or 1:2 for large areas.
The lidocaine also offers analgesia during
infiltration. If one has access to silicone sheets, these maybe placed on the
healed wound under a neck collar or pressure garment. The silicone should
be used continuously for several months and then at night time for a year to
reduce recurrence.
Fig 2
Fig 3
Fig 4
This patient had bilateral severe sycosis barbae and keloid formation. He was draining
from multiple deep sinuses. Multiple secondary tangential excisions with the Weck blade were
required to completely excise all of the deep infected follicles. Fig 2 shows the wound after the
first excision. If cultures can be obtained, appropriate antibiotics should be used. Otherwise
broad spectrum antibiotics are used for these chronic deep infections. Staphylococcus is often
the predominant organism. Skin grafting is carried out only when there is no evidence of
residual infection.
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Fig 5
Fig 6
After a period of oral antibiotic intake and local antibiotic cream application, complete excision
of the keloids, skin grafting and postoperative single-low dose radiation therapy was carried
out. The patient then used silicone sheets for a year, and has not had any recurrences. He uses
depilatory powder for his beard. (Editor’s note: The keloids around the ears in the above
patient are not the typical sycosis barbae keloids. They are not in the heavy beard area and
deep-seated folliculitis is less of a problem and the response to local and oral antibiotics would
typically be better. Low dose preop irradiation, where available, is an excellent way of
preventing keloid recurrence in such cases. The neck keloid is still in the beard.)
Excision and skin grafting of folliculitis keloidalis in the occipital scalp may
create an additional problem in a male of African descent—a bald area which is
cosmetically disfiguring. In such a case, after the skin graft has healed, either
serial excision of the graft or tissue expansion in normal hair-bearing scalp
may be done. Then the unsightly graft may be excised.
If either of these
measures is performed, care must be taken not to close the wound under
tension as this may lead to keloid recurrence. Deep sutures must be taken
between the galea and pericranium so as to limit and relax tension with
closure.
As stated above, when keloids are likely caused by infection, the infection
should be controlled with antibiotics, then excised and closed with flaps
and/or skin grafts.
When tension and infection can be eliminated
postoperatively, these keloids are likely not to recur as in the case below.
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Fig 7
Fig 8
Fig 9
Fig 10
Genital keloids likely secondary to perineal infection: completely excised and closed with
multiple flaps—inner thigh skin advancement flaps, abdominoplasty-like advancement of
upper abdominal skin, TFL flap from left thigh. Wounds closed without tension.
Current algorithms for the treatment and prevention of hypertrophic
scars and keloids by Rei Ogawa, M.D., Ph.D. are shown below. No one will
have all the modalities mentioned but this gives one a guide for possible
treatment.
Conclusion
Understanding the basic phases in the normal wound healing process is
necessary in managing wounds at various stages of healing. Recognizing that
abnormal healing may lead to excessive scar formation and ultimately hinder
function, the surgeon should be alerted to use preventive measures prior to or
after surgery and soon after injury or burns. It is important to distinguish the
two kinds of abnormal scars and to proceed carefully in their treatment in
order that a bad scar is not made worse. Many keloids should not be excised
unless one has the availability of postop low dose radiation. The author has
also used low dose methotrexate systemically after keloid excision but its
efficacy has not yet been proven. Other methods have been used but are either
too expensive or there is not yet good evidence for their widespread use. As in
other wound care, dedicated physician care as well as patient compliance is
required for the best results.
Other chapters will deal with chronic wounds and ulcers and Vacuum Assisted
Wound Closure and skin grafts.
The Most Current Algorithms for the Treatment and Prevention of
Hypertrophic Scars and Keloids by Rei Ogawa, M.D., Ph.D. are shown
below. No one will have all the modalities mentioned but this gives one a
guide for possible treatment.
Ogawa, Rei M.D., Ph.D.
Plastic & Reconstructive Surgery:
February 2010 - Volume 125 - Issue 2 - pp 557-568
(Algorithms used by permission from Lippincott Williams and Wilkins)
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